Makindo Medical Notes

👂 Otitis Externa (OE)

• Likely Causes: Pseudomonas aeruginosa, Staphylococcus aureus, and occasionally fungal (e.g. Aspergillus). Eczema, psoriasis, or contact dermatitis (ear drops, shampoos, earphones) can mimic OE.
• Predisposing Factors: Swimming (“swimmer’s ear”), trauma from cotton buds, hearing aids, narrow ear canals, or humid climates.
• Symptoms: Ear pain (often severe), itching, discharge, conductive hearing loss, tenderness on tragal pressure.
• First-line Management:
  • Aural toilet (careful cleaning by trained clinician or microsuction).
  • Topical antibacterial ± corticosteroid ear drops or spray for 7 days (e.g. Betamethasone + Neomycin + Acetic acid or Ciprofloxacin ear drops if Pseudomonas suspected).
  • Advise to keep ear dry (no swimming, no ear poking).

⚠️ Red flags: Severe pain out of proportion to exam, granulation tissue in the bony canal, or cranial nerve palsy → suspect malignant (necrotising) otitis externa.

🧨 Malignant (Necrotising) Otitis Externa

• Aggressive, potentially fatal infection of the external auditory canal and skull base, usually in elderly diabetics or the immunocompromised.
• Pathogen: Almost always Pseudomonas aeruginosa.
• Clinical clues: Severe unremitting pain, otorrhoea, granulation tissue at canal floor, possible facial nerve palsy or multiple cranial neuropathies.
• Investigations: ESR/CRP (markedly elevated), CT/MRI of temporal bone, ear swab for culture.
• Action: Urgent ENT referral + Consultant Microbiology input. Requires IV antipseudomonal therapy (e.g. Ceftazidime or Piperacillin–Tazobactam) ± surgical debridement. Therapy often continued for 6–8 weeks with follow-up imaging.

👂 Otitis Media (OM)

• Likely Causes: Viral (most common); bacterial causes include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis.
• Pathophysiology: Infection ascends from nasopharynx via the Eustachian tube → middle ear effusion and inflammation.
• Symptoms: Otalgia, fever, irritability, conductive hearing loss, bulging tympanic membrane ± perforation with otorrhoea.
• Guidance: Most cases resolve spontaneously within 72 hours in children. Start antibiotics if:
  • Fever ≥ 38.5 °C or systemically unwell
  • Otorrhoea due to tympanic perforation
  • Children < 2 years with bilateral OM
• First-line: Amoxicillin 500 mg PO TDS for 5–7 days.
• Penicillin allergy: Clarithromycin 500 mg PO BD for 5 days (or Erythromycin if pregnant).
• Complications: Mastoiditis, meningitis, cerebral abscess, facial palsy, chronic suppurative OM.

💡 Tip: Always re-examine at 2 weeks if symptoms persist — persistent effusion (“glue ear”) may require ENT referral.

🩸 Auricular Chondritis / Perichondritis

• Infection of the auricular cartilage (sparing the earlobe) often following trauma, ear piercing, or burns.
• Likely Causes: Pseudomonas aeruginosa (most common), S. aureus.
• Features: Red, swollen, exquisitely tender pinna with normal lobule; may progress to abscess or cartilage necrosis.
• Management: Urgent ENT referral. Requires systemic antipseudomonal antibiotics (e.g. IV Ciprofloxacin or Ceftazidime). May require drainage of abscess if fluctuant.

👃 Acute Rhinosinusitis

• Likely Causes: Mostly viral; bacterial causes include S. pneumoniae, H. influenzae, and anaerobes.
• Clinical pattern: Facial pressure/pain, nasal obstruction, mucopurulent discharge, anosmia, fever.
• Guidance: Usually self-limiting within 7–10 days. Antibiotics indicated only if:
  • Symptoms > 10 days without improvement, or
  • Worsening after 5–7 days (“double sickening”), or
  • Severe/systemic illness (fever, facial swelling, orbital pain).
• First-line: Amoxicillin 500 mg PO TDS for 5 days (alternative: Doxycycline 100 mg PO BD for adults).
• Adjuncts: Nasal saline irrigation, decongestant spray (short term only), intranasal corticosteroid (if allergic component).

🏥 Chronic / Refractory Sinusitis

• Definition: Symptoms persisting ≥12 weeks with endoscopic or imaging evidence of sinus inflammation.
• Empirical Treatment: Co-amoxiclav 625 mg PO TDS for up to 3 weeks.
• Penicillin allergy: Often Doxycycline + Metronidazole (consult Microbiology).
• Referral: ENT for possible functional endoscopic sinus surgery (FESS) or polypectomy.

🧾 Pharyngitis / Tonsillitis

• Likely Causes: Viral (≈80%); bacterial most often Group A β-haemolytic Streptococcus (Strep pyogenes).
• Symptoms: Sore throat, fever, dysphagia, tonsillar exudate, tender anterior cervical lymphadenopathy.
• First-line: Phenoxymethylpenicillin (Pen V) 500 mg PO QDS for 10 days.
• Penicillin Allergy: Clarithromycin 500 mg PO BD for 5 days.
• Complications: Peritonsillar abscess (quinsy), otitis media, post-streptococcal glomerulonephritis, rheumatic fever.

📊 CENTOR Score

• Tonsillar exudate
• Tender anterior cervical lymph nodes
• Absence of cough
• History of fever

CENTOR ≥ 3 → consider antibiotics. CENTOR < 3 → likely viral → supportive care (fluids, paracetamol, throat lozenges). Note: Rapid antigen tests (RADT) increasingly used in primary care to confirm GAS.

🫁 Acute Epiglottitis / Supraglottitis

⚠️ Emergency: Risk of sudden airway obstruction. Do not attempt throat examination or swabbing. Ensure anaesthetic and ENT presence before any airway intervention.

• Likely Causes: H. influenzae (type b), S. pneumoniae, S. aureus.
• Presentation: Rapid onset sore throat, fever, drooling, stridor, muffled “hot-potato” voice, tripod posture.
• Investigations: Secure airway first. Then blood cultures; lateral neck X-ray (thumb-sign) if safe.
• Treatment:
  • Ceftriaxone 2 g IV OD (or Cefotaxime 2 g IV 8-hourly).
  • Airway management: Urgent ENT + Anaesthetics/ICU input.
  • If septic shock → aggressive IV fluids, early critical care review.
• Adjuncts: Dexamethasone IV to reduce airway swelling; oxygen humidified; monitor in HDU/ICU.

📚 References

• BNF / NICE CKS: ENT infections
• NICE CKS: Acute Otitis Media
• NICE CKS: Acute Sinusitis
• NICE CKS: Sore Throat / Tonsillitis
• NICE CKS: Epiglottitis

🕓 Revisions

• 2025-10 — Reviewed and expanded by Dr O’Kane (Makindo edition)